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    Fluid Volume Deficit

    Uploaded by

    Ruby Anne
    The document summarizes the problem, intervention, and evaluation of a patient who suffered blood loss from a gunshot wound. The immediate problem was severe bleeding and potential for hypovolemic shock. The short term goal was to maintain fluid volume after 6 hours of intervention. The long term goal was for the patient to monitor and correct fluid deficits independently after 1-2 days. The interventions included assessing vital signs, encouraging fluid intake, monitoring intake/output, changing positions frequently, and administering IV fluids or blood products as needed. The evaluation criteria was normal vital signs, consciousness level, and urine output indicating the patient was maintaining proper fluid volume.

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    Fluid Volume Deficit

    Uploaded by

    Ruby Anne
    1K views2 pages
    The document summarizes the problem, intervention, and evaluation of a patient who suffered blood loss from a gunshot wound. The immediate problem was severe bleeding and potential for hypovolemic shock. The short term goal was to maintain fluid volume after 6 hours of intervention. The long term goal was for the patient to monitor and correct fluid deficits independently after 1-2 days. The interventions included assessing vital signs, encouraging fluid intake, monitoring intake/output, changing positions frequently, and administering IV fluids or blood products as needed. The evaluation criteria was normal vital signs, consciousness level, and urine output indicating the patient was maintaining proper fluid volume.

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    Fluid volume deficit

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    The document summarizes the problem, intervention, and evaluation of a patient who suffered blood loss from a gunshot wound. The immediate problem was severe bleeding and potential for hypovolemic shock. The short term goal was to maintain fluid volume after 6 hours of intervention. The long term goal was for the patient to monitor and correct fluid deficits independently after 1-2 days. The interventions included assessing vital signs, encouraging fluid intake, monitoring intake/output, changing positions frequently, and administering IV fluids or blood products as needed. The evaluation criteria was normal vital signs, consciousness level, and urine output indicating the patient was maintaining proper fluid volume.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views2 pages

    Fluid Volume Deficit

    Uploaded by

    Ruby Anne
    The document summarizes the problem, intervention, and evaluation of a patient who suffered blood loss from a gunshot wound. The immediate problem was severe bleeding and potential for hypovolemic shock. The short term goal was to maintain fluid volume after 6 hours of intervention. The long term goal was for the patient to monitor and correct fluid deficits independently after 1-2 days. The interventions included assessing vital signs, encouraging fluid intake, monitoring intake/output, changing positions frequently, and administering IV fluids or blood products as needed. The evaluation criteria was normal vital signs, consciousness level, and urine output indicating the patient was maintaining proper fluid volume.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    CUES

    PROBLEM

    SCIENTIFIC REASON The immediate damaging effect of the bullet is typically severe bleeding, and with it the potential for hypovolemic shock, a condition characterized by inadequate delivery of oxygen to vital organs.

    DESIRED OUTCOME Short term goal: After 6 hours of nursing intervention the patient will able to maintain fluid volume at a functional level. Long term goal: After 1-2 days of nursing intervention patient will be able to demonstrate behaviors to monitor and correct deficit as indicated.

    INTERVENTION/ RATIONALE Assess vital signs, noting low blood pressure, rapid heartbeat, and thread peripheral pulses. These changes in vital signs are associated with fluid volume loss and/or hypovolemia. Keeps fluids within clients reach and encourage frequent intake as appropriate. Maintain accurate I&O and weight daily. To monitor accurate fluid intake and output. Change position frequently. To reduce pressure

    EVALUATION STANDARD CRITERIA The client demonstrated behavior to monitor and correct fluid volume deficit as evidenced by normal level of consciousness , normal pulse rate (74bpm) and normal urine output (1500cc/day)

    Subjective: Fluid volume Madaming dugo ang deficit related nawala sakin as to blood loss verbalized by the as evidence patient. by gunshot wound. Objective: Pale conjunctiva High Hematocrit (0.384 g/l) Low RBC count (2.50x109 g/l Low hemoglobin count (67.1 g/l) Low MCHC (mean corpuscular hemoglobin concentration, 296g/l)

    The Client will remain fluid volume balanced

    (Source: http://en.wikipedi a.org/wiki/Ballisti c_trauma)

    Increased pulse rate (120bpm) Decrease urine output (56 cc/day) Decrease level of consciousness

    on fragile skin tissues. Administer IV fluids as indicated. To replace fluid losses. Replace blood product as ordered. To replace fluid blood loss. Establish 24-hour of fluid replacement needs and routes to use. To prevent peaks and valleys in fluid level.

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